Nursing Care Plan

 


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Medical Diagnoses:  Chronic renal failure, Arthritis, Generalized Pain, Dysuria, Anemia, HTN, GERD, Early Stage Dementia, Anxiety, Osteoporosis

      

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

         

         

         

“My hip is hurting from when I broke it.”

         

         

Objective:

         

Client does not ambulate.


Problem

      

      

Chronic Pain

      

      

Long Term:

Client will function with minimal interference from pain, rated  as 3 or less on a scale o f 0-10 within 2 months.  Client will function with minimal interference from medication side within one week..

Tell the client to report pain location, intensity and quality when experiencing pain.  Assess and document the intensity of the pain with each new report of pain and at regular intervals.   Systematic ongoing assessment and documentation provide the direction for pain treatment plans ; adjustments are based on the client’s response. (Nursing Diagnosis Handbook, Ackley and Ladwig, pg. 613)

N/A

The client will report pain at less than three on a scale of  0-10.

The nurse will help the client by repositioning to avoid pressure on the healing hip, administer medications as indicated by pain level and call physician to change medication if pain is unrelieved by prior intervention.s

R/T

      

      

Progression of joint deterioration, injury, surgical procedure, and chronic kidney disease

      

      

      

      

Short Term:

         

Use pain rating scale to identify current level of pain intensity, and determine comfort/function goal.

Ask the client to describe past and current experiences with pain and the effectiveness of the methods used to manage the pain, including experiences with side effects, typical coping responses and the way the client expresses pain.  A study revealed that barriers can affect a client’s willingness to report pain and use analgesics.  Many harbored fears and misconceptions regarding the use of analgesics, management of side effects and risk of addiction.

N/A

      

      

AEB

      

as evidenced by patient self report of pain level.

      

      

      

      

      

      

      

*I = Implementation.  Check those interventions/actions/orders that were implemented

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Medications

Name/Dose

Why does resident receive?

Major Side Effects

Nursing Implications

         

Lorazepam 0.25 mg, every 8 hours, PRN.

         

         

Anxiety

Anterograde amnesia, drowsiness, sedation, dizziness, weakness, unsteadiness, disorientation, depression, sleep disturbances, restlessness, confusion, and hallucinations

Supervise ambulation of older patients for at least 8 hours after administration to prevent falling and injury.

         

Premarin-0.625 mg/1 gm cream

         

         

Vaginal dryness, itching and burning

Vaginal discomfort or pain, itching, breast pain, vaginitis

Monitor for and report any vaginal bleeding, assess for relief of symptoms

         

Metoprolol XL 25 mg once daily

         

         

Hypertension

Erythematous rash, fever, headache, muscle aches, sore throat, laryngospasm, respiratory distress, dizziness, bradycardia, fatigue, insomnia, mental depression, Raynaud’s phenomena, nausea, heartburn, dry mouth and mucous membranes, hypoglycemia, SOA

Take apical pulse and BP prior to administration, report significant changes, monitor I&O, daily weight, auscultate daily for pulmonary rales, withdraw drug if patient exhibit mental depression, can progress into catatonia. 

         

Acetaminophen

-500 mg PRN q 4

         

Pain

Neglible with recommended dosage, rash

Monitor for s/s of hepatotoxicity.

Maalox 30 mL q6 PRN

         

GERD


Chalky taste, constipation, diarrhea, increases thirst, stomach cramps

Monitor for s/s of allergy, monitor bowel elimination

Hydrocodone 5/500 PRN q6, not to exceed 4 gm per 24 hours

Pain

Dry mouth, constipation, nausea, vomiting, light-headedness, sedation, dizziness, drowsiness, euphoria, dysphoria

Monitor for effectiveness of pan relief, monitor for n/v, especially in ambulatory patients, monitor respiratory status and bowel elimination

Senna 8.6 mg

Constipation

Strong cramping and griping pains in the abdomen, electrolyte imbalance (loss of potassium) and loss of body fluids, nausea, rash, swelling of the fingertips, weight loss, and dark pigmentation in the colon

Monitor for effectiveness of bowel relief, monitor for electrolyte imbalances, monitor for n/v, monitor for rash

Furosemide 10 mg

Hypertension/Renal Failure

Hypotension, dizziness with excessive diuresis, hypovolemia, dehydration, hyponatremia, hyperglycemia, anemia

Monitor BP during periods of diuresis, monitor I&O ratio and pattern, monitor for dehydration and hypovolemia, monitor glucose, monitor for electrolyte imbalances

Ferrous Sulfate 325 mg

Anemia

Nausea, heartburn, anorexia, constipation, diarrhea, epigastric pain, abdominal distress, black stools.

Monitor HgB and reticulocytevalues during therapy.  Monitor bowel movements.

Ibuprofen  400 mg

Pain

Headache, dizziness, light- headedness, anxiety, emotional lability, fatigue, drowsiness, confusion, depression, aseptic meningitis, dry mouth, GERD, v/n/d, acute renal failure, GI bleeding

Monitor for effectiveness, periodic Hgb, renal and hepatic function and auditory and ophthalmic examinations.  Monitor for GI distress and S/s of GI bleeding.

Calcium Carbonate

Indigestion/hyperphosphatemia

Constipation or laxative effect, acid rebound, n/v, flatulence

Monitor for bowel functio, determine serum and urine calcium, observe for s/s of hypercalcemia

4.     

         


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